Provider First Line Business Practice Location Address: 
634 SUMMIT AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JERSEY CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07306-3705
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-222-9370
    Provider Business Practice Location Address Fax Number: 
201-222-9392
    Provider Enumeration Date: 
10/01/2014